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1. Heroin today: commodity, consumption, control and care PDF Print E-mail
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Books - A Land Fit for Heroin
Written by ISDD research and development unit   

ISDD Research and Development Unit

'The word narcotic comes from a Greek word meaning "stupor". Stupor is a state of reduced sensibility that has given rise to our familiar adjective stupid.' (Weil and Rosen, 1983, p. 80)

Heroin is a beige, brown, grey, off-white or sometimes pinkish powder that is derived from the opium poppy which grows in many parts of the world. Pharmacological 100 per cent pure heroin is white, but different manufacturing processes and additives give it a variety of shades.

Origins of heroin

Heroin is made from the opium poppy — Papaver somniferum. Raw opium is collected from the seed-pods of the poppy by making incisions in the pods and scraping off the liquid that seeps out and congeals on the outside. This congealed resin-like material is mixed with water to which lime has been added, producing a form of morphine — the intermediate stage between opium and heroin. The morphine is treated with other chemicals to produce a precipitate of heroin, which is then dried to produce granules or powder. Production processes are basically similar whether the drug is being made legally or illegally.

About 200 kilograms of heroin per year is legally manufactured in Britain (International Narcotics Control Board, 1984; Home Office Drugs Branch, personal communication, 1984). The bulk of this legally and domestically manufactured heroin is used as a pain-killer in medicine, less than 5 per cent being prescribed as 'maintenance' doses of heroin for some of the addicts attending drug dependency units (Home Office Drugs Branch, personal communication, 1984). The drug dependency units (clinics) have for many years been cutting down on the amount of heroin prescribed, and the amount of heroin being illegally imported has risen, so heroin obtained from clinics now forms a very small proportion of the total amount used for recreational and other illegal purposes.

Most of the heroin used illegally in Britain is imported from countries in south-west and south-east Asia, being produced in small illicit 'kitchen' factories and smuggled into Britain by courier or hidden inside other goods. This heroin — sometimes prepared for smoking and sometimes for injection — may be 'cut' or diluted with other substances after entry into Britain. At the present time the purity of heroin samples remains quite high, averaging between 70 and 90 per cent on entry into Britain (O'Neil, P. et al. , 1984, pp. 889-902) and 20-50 per cent 'on the street' (though it may vary considerably from one sample to another).

Availability

Heroin, it is claimed, is available for sale in most towns in Britain (if you know where to go and whom to ask), but this availability probably fluctuates from one town to another and from time to time. In large conurbations and their environs there may be a more ready and stable supply, since several sources of supply will coexist.

Whether the main factor expanding heroin use over the past few years has been the ready supply at international level, the actions of criminal organisations that have increasingly moved into international drug trafficking, illegal 'small business' activity by persons in areas lacking many other economic opportunities, or increased demand for the drug is a matter of contention. Perhaps each of these factors is in some way responsible, but we do not know to what extent. Recently the price of good-quality heroin has dropped, and this may be partly due to economies of scale associated with a larger distribution network for the drug in many parts of Britain and elsewhere. This expansion of the market may be most accounted for by increases in heroin smoking, about which we say more later.

The range of effects sought by users

There are four aspects of the effect of heroin that are experienced at the time of taking it.

Pleasure

Heroin users may smoke, snort or inject the drug. Injection may be directly into a vein, into a muscle, or into the flesh just under the skin (which gives a slower diffusion of the drug into the bloodstream). Snorting involves absorption through the membranes in the nasal passages and this also slows down the speed at which the drug reaches the brain, when compared with intravenous injection. Smoking the drug provides a slightly faster route to the brain than injection or snorting, but some smokers may take their dose in stages rather than all at once (which is the standard procedure with injection).

Many heroin users — particularly those who inject directly into a vein — report that they experience a 'hit', 'flush' or 'rush' which is intensely pleasurable. This reaction is related to the initial effect of heroin on the body, and is short-lived. Not everyone experiences the 'rush' as pleasurable, and many new users feel violently sick at about the same time. These feelings of nausea generally subside if the person persists in using the drug.

Those who do persist in using the drug and begin to do so fairly regularly find that they become accustomed to the initial effects (technically, this is an aspect of the body's 'tolerance' to the drug — see below) and they may wish to increase the dose in order to get as much pleasure as they first experienced.

Once it has been taken into the body by injection, smoking or snorting and passed through the blood—brain barrier, heroin has a 'half-life' of only two and a half minutes (meaning that the amount of heroin in the body is halved, then halved again, etc, every two and a half minutes). It is rapidly converted into morphine, which is responsible for subsequent and longer-lasting effects (Stimmel and Kreek, 1975).

Relaxed drowsiness — a mixture of euphoria and tranquillity

Depending upon the dose taken, the user may continue to interact socially in a relaxed manner; or may become more introspective and go 'on the nod' (so called because of the lolling of the head); or may 'crash out' into unconsciousness (potentially dangerous). Most users probably aim for a state of mind which combines continuing consciousness with relaxed feelings, though established users of high doses may crash out following their enjoyment of the initial rush. Those who go 'on the nod' may sometimes be more alert and attentive than they seem, being able to respond rapidly to any sudden change in the situation around them. It is possible that different users pay primary attention to different parts of the experience of intoxication and its aftermath.

Relief from anxiety and pain

In common with other derivatives of the opium plant (opium itself, morphine, codeine) and some synthetic opiate-type drugs (methadone, etc.) heroin may distance the user from physical pain and from psychological states such as fear and anxiety, or alternatively may modify the perception of pain or anxiety so as to make it more tolerable. For as long as the state of intoxication lasts — and this may be several hours, depending upon the dose and other circumstances — so the person will be shielded from the full impact of pain and anxiety.

This property of the drug may be valued by those users who suffer some kind of distress and wish to set it aside, albeit temporarily. Such users, if they become regular users, may find withdrawal from the drug and staying off particularly difficult since the loss of the pleasurable effects of heroin will coincide with the reappearance of their original distress. Other users, however, who are not initially motivated to take heroin to mitigate distress and who do not learn to use heroin in this fashion (perhaps because they are not very distressed or anxious) will be more likely to focus upon the positive reasons for using. It is perhaps such users who find it easier to use heroin episodically and recreationally at some times and to go without at others. (See subsequent sections for more on dependence and withdrawal.)

Cultural, situational and motivational aspects 'steering' the drug experience

Besides heroin's particular pharmacological actions, the circumstances in which people use the drug will also influence the sorts of experiences that they have when they take it. Not only their motivations for using the drug (e.g. for pleasure, to escape pain, for exploration, to be like a friend, or a combination of these and other reasons) but also the immediate situation in which use occurs (who, if anybody, is present or may arrive, what activities are occurring, what interpretations of their experiences are offered by others?), and the culture or subculture which frames such situations and gives them meaning — all these may play a part in steering the drug effects one way or another.

For example, solitary users may be more likely to go 'on the nod' or go to sleep than people who use drugs in a group involved in conversation or other social activities (though the whole group may become drowsy if this is their preferred experience). Alternatively, people whose main interest is in the initial rush may make efforts to emphasise this and to disregard or overcome the following sedation — perhaps with the aid of stimulants.

The existing drug literature tells us very little about the cultures, situations and motivations informing the drug use of the new wave of young heroin smokers and snorters, about their dose levels or frequencies of use, or about the ways in which these groups seek to 'steer' their drug experiences or the effects they get. Most of our up-to-date information comes by word of mouth from street agencies and other non-statutory and statutory agencies. Such observers speculate that the mode of administration — i.e. smoking or snorting — may have consequences for the drug experience which differ from those of injection. Smoking may to some extent appear to 'normalise' the activity in comparison with injection (which is rare in everyday life and which has medical and other connotations). It has also been suggested that, as the number of people who use or have used a drug increases, so such people become less distinguishable from the general population:

as notorious drugs (such as use of heroin) become more widespread in a population the people using them are likely to be more normal (statistically and in other senses) than the abnormal population who presented originally. When a city with a couple of million inhabitants has only one or two dozen heroin users then this group will probably be deviant and abnormal in many- ways; but as this behaviour becomes more widespread the abnormal characteristics will become less noticeable. By the time there are several hundred thousand drug takers in such a city their characteristics would be much more similar to the non-using population. This is not to say that such changes are not a cause for concern and do not warrant serious consideration and response; it is meant to illustrate that the different status of this group becomes progressively less apparent as the drug-using population increases (Strang, 1984, p. 1204).

The consequences of this possible 'normalisation' — and' the circumstances in which it is most likely to occur — are not known. One consequence might be that most drug users have fewer health and social problems, as they no longer identify with 1960s and 1970s stereotypes of the 'messed-up addict' and as extreme public reactions against them lose momentum. It is possible, therefore, that as Britain's heroin problem expands in terms of numbers of ever-users, so the problems of the average user become less serious.

Patterns of use and their consequences

In this section we discuss patterns of heroin use in terms of frequency and regularity of use (that is, users can be regular or episodic users), and in terms of the mode of administration (smoking or snorting, or injection into the skin or veins).

Defining what is meant by 'regular' use is not easy. We take it to mean either daily use (once or more per day) or fairly consistent use at particular times of the week (for example, on particular days, over the weekends, or at some other stable time and place). Occasional or episodic use, on the other hand, is use that occurs less frequently or in no consistent pattern.

Estimates made in the early 1980s of numbers of persons using opiate-type drugs 'regularly' and probably dependent upon them to some extent varied from 25 000 to 40 000, depending upon whether one was interested only in those using at a particular point of time, or those using regularly at some time or another during a given year (Advisory Council on the Misuse of Drugs, 1982). These figures were approximately five times the number of persons then officially notified to the Home Office as being 'addicts' — figures supplied by doctors in drug clinics, prisons, hospitals, general practice and private practice. Most regular users are, therefore, not in treatment. Most regular users throughout the 1960s and early 1970s were injecting the drug (antl generally injecting other drugs, including barbiturates and/or synthetic opiates, as well) but from the late 1970s smoking and snorting became increasingly common.

It is possible to Smoke or snort regularly or occasionally — though there is always a danger of moving from occasional use to more, frequent use (and dependence), and from smoking or snorting to injection. We simply do not know what the likelihood is of such progression within any of the social groups amongst whom heroin smoking has recently expanded.

Regular injection is now probably the least common form of involvement with heroin in Britain — not because it has become less common, but because other forms of use (smoking and snorting) have become more common. The consequences of regular injection fall into two categories:

•    consequences of injection as a means of administration (that is, also experienced by occasional injectors), and
•    consequences of regular use (mainly, the development of tolerance and almost certain dependence).

Consequences of injection

Injectors, whether regular or irregular users, face three specific consequences not faced by non-injectors.

•    In the first place, their mode of administration typically delivers the whole dose into the bloodstream in one batch. Because all the drug goes in at once, it is not possible to regulate the dose in response to felt effects, as is possible in snorting or smoking. Overdose is more likely with injection than with snorting or smoking.
•    In the second place, injection carries specific dangers of infection, related to some users' lack of stable housing and other facilities necessary to maintain cleanliness, and to their failure or inability to use sterile equipment and water (in which heroin is 'cooked up' to dissolve it prior to injection). Hepatitis and other infections, including HIV (the AIDS virus) can be passed from one user to another if they share a needle. Veins may be damaged by injection, especially if material not totally soluble in water is injected, as may happen when heroin is adulterated with insoluble material or when other opiate-type and sedative drugs are injected in the absence of heroin or in preference to it.
•    Lastly, injection carries certain symbolic aspects (though these may vary from group to group), and not only the users themselves but also non-users aware of their practice-may react to injectors in specific ways that mark them off from 'the normal'. Thus the mode of administration may have consequences for how users perceive themselves and their drug use, and hence consequences for their future use of drugs: some injectors may become quite involved in playing at the role of 'addict'.

Heroin presents particular dangers to women. Women's bodies generally and their livers particularly are smaller than men's, and women are thus more at risk of liver damage. Oral contraceptives place a strain on the liver, making it more hazardous for women using such methods of contraception to use heroin. Frequent, regular heroin use causes women's periods to stop, though pregnancy is still possible since other aspects of the menstrual cycle continue. As with other sedatives, heroin passes to the unborn baby and sedates him or her, with the results that growth may be slowed and withdrawal occur at birth (DAWN, 1984, p. 4).

As far as the development of a 'habit' is concerned, two aspects of regular heroin use are significant: the development of tolerance (a physiological phenomenon), and the potential for dependence (a psychological as well as physiological state). Tolerance, as already noted above in the section on drug effects, is the process whereby the user's body begins to adapt to the presence of the drug. Regular, frequent (for example, daily) users generally experience a degree of tolerance. There is some evidence that the development of tolerance varies with the person's circumstances and expectations. High-dose hospital patients, for example, who are given the drug in the context of no history of its abuse, are less likely to experience tolerance than are regular street users. Tolerance to different aspects of the drug's effects develops at different rates, so some users may increase their dose in pursuit of ofié effect (for example, euphoria) even though the body may not have adapted in other ways. One consequence of the development of tolerance is that users may edge their dose upwards in order to get the same 'rush'. Another consequence is that overdoses may occur if a hitherto regular user stops using for a while-and then resumes at their previous dose level.

Dependence means that a person has come to rely upon the drug to feel normal. A person who has become dependent on heroin or similar sedating drugs experiences discomfort withdrawal symptoms') if he or she cuts down on the dose rapidly or stops using the drug for a day or two. Withdrawal symptoms, which in their physical aspects resemble influenza, vary in their severity according to the dose of heroin to which the person has become accustomed and according to their expectations and motivations. It should be noted, however, that even occasional users may become dependent on the drug to get them through certain situations or to provide an occasional diversion or reward — there are different kinds of dependence. For a discussion of withdrawal and its management, see Yates (1982) and Blenheim (1983).

Summarising: regular injectors face the greatest dangers of infection, physical (e.g. venous) damage, dependence, and social stigmatisation. They may however develop a degree of practical knowledge and expertise that helps them to minimise some of these risks. Their development of tolerance to drug effects may reduce the chances of accidental overdose for as long as they remain regular users, but if they discontinue heroin use (hence losing their tolerance) and then resume heroin use at their previous dose, they will be at particular risk of overdosing.

Episodic injection

Those heroin users who inject it only occasionally, or in short 'runs' of, say, once a day for a few days, or who inject once or twice a week or less on average but not in any regular pattern — are less likely to suffer some of the adverse consequences of regular users. That is to say, irregular users generally do not develop tolerance, and will not need to increase their dose to get satisfaction (though they may, of course, still choose to move to a higher dose, or drift into doing so). They also run a lesser risk of dependence than do regular injectors, since their bodies do not become adapted to the fairly continual presence of morphine metabolites. They may however find that they have become dependent on the use of the drug at certain times that, might otherwise be trying or anxiety-producing. There is a clear risk of progression from injecting a few times to more regular and dependent patterns of use.

Other than this, episodic injectors run all the risks of injection (already mentioned), though less often than regular injectors. Episodic injectors may or may not be in good health generally and in materially and emotionally secure environments, and these aspects are likely to influence their experience of drug use and the consequences for physical and mental health.

There is one respect in which irregular injectors may be at greater risk than regular users. 'The risk of overdose may sometimes be higher in casual and intermittent injectors because of their lack of tolerance and lack of experience in finding out from their suppliers exactly what (and in what strength) they are taking.

Persons who inject heroin regularly at one time may discontinue at other times — and vice versa. Injectors may, in other words, vary their level of involvement with drugs as time goes on.

An unknown number of people smoke and/or snort heroin on a fairly regular basis — once a day, say, or at weekends. Snorting seems to have followed cocaine use in some middle-class circles, while smoking (including 'chasing the dragon') has been widely reported in both working-class and middle-class areas. Until the early or mid-1980s, it seemed to be primarily males who were involved in smoking, but more recent reports from street agencies and other sources suggest that women's involvement has been increasing. (Most recreational drug practices have historically first been taken up by men and then filtered through to women who have used illegal drugs less heavily in many cases.) And, in contrast to the 1970s, some agencies report that they are beginning to be approached by heroin users of Asian and African descent.

Smoking heroin is done by placing the drug on a piece of metal foil or similar object, heating it from underneath until it smokes, and then drawing in the smoke by means of a straw, funnel or like object (this is called 'chasing the dragon'). Alternatively, but less commonly in this country at the present time, heroin or other opiates may be mixed with tobacco or other smoking substance and smoked in a pipe or rolled cigarette. An amount of heroin can also be picked up on the glowing tip of a cigarette. In any case the smoke is drawn into the lungs.

Snorting heroin is done in a manner similar to sniffing other substances such as snuff or cocaine. In this case part of the drug is absorbed by the nasal lining, and hence passes into the bloodstream.

Neither smoking nor snorting heroin carries any major dangers specific to these modes of administration other than incidental dangers of smoking tobacco when the drug is mixed with it. Both methods are less dangerous than injection, in so far as risks specific to injection are avoided.

Regular, frequent use of heroin by smoking or snorting however, does carry with it the probability of developing tolerance, wishing to increase the amounts used, becoming dependent, and suffering discomfort if one does not continue the pattern of use to which one has become accustomed. There may also be social, financial, legal and other problems (see below). There is also the possible danger of switching to injection to maximise the effect, a development that some street-agency staff suggest may occur amongst those who have been smoking heroin regularly and heavily over a year or more.

Episodic smoking or snorting

This is probably the most widespread of all present-day involvements with heroin, yet least is known about it. Of the two modes of administration, it is smoking which is reportedly most widespread. The typical episodic smoker is white, but there is no clear social-class profile. 'There have been reports of large numbers of such users in inner-city areas of decline and mass unemployment. These reports may be triggered partly by a general concern about unemployed youth and their social behaviour and future development, rather than by any real concentration of heroin users in such areas. In any case, there are also reports of young people from middle-class backgrounds, both employed and unemployed, smoking heroin, so this form of drug involvement should not be linked solely with social deprivation.

It seems more plausible to describe the spread of the Practice as one aspect of young people's boredom, desire for excitement and pleasure, involvement in getting hold of the drug by participating in aspects of a petty criminal 'irregular economy', and a willingness to try a drug that can be administered in a way that builds upon existing practices (for example, smoking cigarettes, cannabis). See Auld et al. (1986) and Pearson (in this volume) for further discussion.

Summarising the last few paragraphs, we can say that whilst occasionally smoking and snorting heroin carry a range of dangers, these dangers are multiplied by regular use and by injection. But things are more complicated than this. So far we have been talking as if people took heroin pretty much in a vacuum, and as if the consequences of their use of the drug depended solely upon how much they took, by what means and how often. There are other issues that interact closely with heroin use.

Overdoses

One important cause of death amongst users of heroin and other sedating drugs is overdose (Spear, 1983; ISDD, 1986, p. 6). Overdoses are caused by taking too much of a particular drug (e.g. heroin or barbiturates) at one time, or by mixing drugs (taking two or more sedating drugs within the same period of time). The actual cause of death in many cases of overdose is respiratory failure (inability to breathe) because of airways being blocked by vomit inhaled into the lungs.

In some respects regular heavy use of heroin is less dangerous than regular heavy use of barbiturates. This is because tolerance develops to the respiratory depressant effects of heroin but not to those of barbiturates, making it easier for the heroin-overdosed person than for the barbiturate-overdosed person to keep breathing. So a tolerant heroin user who increases his or her dose to overcome tolerance and hence experience the drug's euphoric effects is less likely to die than is a barbiturate user who increases his or her dose of that drug.

Because tolerance is lost if the regular user discontinues drug use for a period of time, such people are particularly at risk to overdoses. Such people may not realise that a spell in prison or a period spent drug-free in treatment and rehabilitation will cause them to lose tolerance, and may therefore re-start drug use at their old dose level, resulting in an overdose. This danger occurs with sedatives generally, not just heroin, and it may be appropriate for professionals such as probation officers and rehabilitation staff to warn clients of it.

Countermeasures

Countermeasures to an overdose by heroin and alcohol, alcohol alone, other sedatives, or a combination of these are quite simple. It is no good giving stimulants (either pills or coffee). If a person is fully conscious, but is suspected of having taken an overdose of sedatives by methods including swallowing, eating or drinking, then s/he should be encouraged to be sick to remove alcohol or other sedative stomach contents. This is however not an entirely safe procedure if the person is not fully conscious and alert, since vomit may lodge in the airways and prevent breathing.

In all cases of suspected overdose — and especially when the person is drowsy, unconscious, or has slow or uncertain breathing or heartbeat — an ambulance should be called to take them to the Accident and Emergency Department of the nearest hospital without delay. Meanwhile, it is essential to maintain an adequate airway, to make sure that their breathing is unrestricted, and to lie them on their side with their head turned slightly towards the floor (so that any vomit has a chance of dropping out of the mouth rather than falling back to obstruct the airways). If in doubt, the safest course of action is to call an ambulance. Standard first-aid resuscitation may be necessary (Readers Digest' AA, 1985; Campbell, 1984).

Drug interactions and life-style

Many deaths that occur amongst heroin users are due to their use of a variety of drugs, and/or to general neglect and ill health amongst that proportion who take drugs in particularly adverse conditions. Heroin is a sedating drug, as the effects once the initial 'rush' has passed make clear. Alcohol is another s,edating drug (as are barbiturates and other hypnotics, major and minor tranquillisers and, broadly speaking, solvents that may be sniffed). When two or more of these drugs are taken during the same period of time, their effects tend to interact to produce a more powerful effect, with consequences that include increased risks of accidents (for example, falling, driving accidents, etc), lo'ss of consciousness and possible death due to respiratory failure.

One American study (of injectors) found that the only factor differentiating a sample of dead heroin users from a matched sample of living users was the former's heavy use of alcohol (Baden, 1972). It seems likely, therefore, that drinking provides the general or specific conditions in which heroin may be more likely to cause death by overdose. Use of other sedating drugs alongside heroin — such as barbiturates, tranquillisers, and synthetic opiate-like drugs (for example, methadone) — similarly increases the danger of overdose and death, but it is worth emphasising alcohol since it is often overlooked even though it is used quite heavily by many users of illegal drugs (see Rounsaville
et al. , 1982).

It makes sense, therefore, to warn heroin users of the special dangers of drinking when they are high, and to warn drinkers who are in conditions where heroin is relatively freely available not to use it then. Whilst there is no direct evidence on this point, it seems prudent to assume that smokers and snorters, as well as injectors of heroin, are at risk when drinking or using other sedating drugs.

It should also be remembered that some casualties are the result of a combination of particularly hazardous forms of drug use (for example, injection of a variety of substances) and poor environmental, economic and social conditions. Street agencies and other statutory and non-statutory agencies have evolved a variety of approaches towards helping people in such circumstances (Blenheim Project, 1983; DAWN, 1984; Dorn and South, 1985).

Criminality and heroin

The idea that heroin use leads to crime is put forward today almost as a matter of common sense. The popular argument is that people turn to property crime (and may employ violence) in order to support their heroin habits. The argument was originally applied, to American heroin injectors and has recently been extended to young heroin smokers. But the evidence for this idea has always been very 'shaky', and it seems probable that the relationship between drug use and crime is more complex than this:

There is no evidence that opiates are a cause of crime in the sense that they invariably lead to criminality, but there is no doubt that among those addicts with a delinquent life-style drug use is part and parcel of their other activities, crime included (Research Triangle, 1976).

In what follows it needs to be remembered that, by definition, possession of illegal drugs is itself a crime: we are talking about the relation between this and other forms of criminal behaviour.

British studies of drug users suggest that 'no drug has inherent criminogenic properties' (Mott, 1981). Most males notified to the authorities as addicted to opiate drugs were convicted of offences before being notified. Studies in several other countries also suggest that people typically become involved in petty crime first and in heroin later. For example: 'Drug addiction is one of the later phases of the criminal career rather than a predisposing factor' (Meyer, 1952). Some young people already marginally involved in non-drug crime may increase such involvements at the same time as they become involved in drug use, but this in itself is not evidence that the drug use caused the increase in crime: 'While crime may increase, it may have happened anyway, given the fact that most contemporary addicts are at an age which is also a high risk age for crime' (Greenberg and Adler, 1974).

Income sources

Accepting, for a moment, that not all drug users support their consumption by means of property crime — how do they finance themselves? In trying to answer this question it may be useful to look at the results of American studies, since the levels of heroin use and the surrounding social conditions in Britain today are becoming more like those prevailing in inner-city areas of the USA in previous decades. American studies found that the greater part of heroin users' incomes come from sources s'uch as legitimate employment (for some users), unemployment and welfare payments (for the unemployed), and from dealing in illegal drugs themselves: only a small part comes from non-drug crimes such as property crimes. The heavier the person's consumption of heroin, the more likely is he or she to firtance some of this consumption through drug dealing, supplying less frequent users. One review observed that 'a significant percentage (probably between 30 and 50 per cent) of the income needed to support large habits is generated within the drug distribution network itself (that is, by buying or selling illegal drugs). Evidence also indicates that a substantial number of heavy users of expensive drugs obtain substantial financial support from family, welfare and employment' (Wardlaw, 1978, p. 89).

As another major review put it: 'It is becoming increasingly clear that drug use is supported through a variety of legal and illegal sources other than predatory, income-generating person or property crime' (Research Triangle, 1976, p. 21). Of these various sources of income, part-time jobs, occasional paid services for jobs such as car-washing or fetching and carrying, and support from family members are likely to be significant for today's younger heroin users who smoke or snort (or even inject) it on an episodic basis.
There is clearly some danger in suggesting to young people that if they have experimented with heroin, then they are expected to begin to steal. Not only would any such suggestion not be justified in terms of the available research — it would possibly promote an increase in petty crime amongst young people who had become aware of the possibility of saying couldn't help it'.

When crime leads to drug use

Although heroin use does not generally cause crime (other than by definition, since possession of certain drugs including heroin is illegal unless prescribed) heroin use is often associated — on a statistical basis — with certain kinds of income-generating property crime. (that is, there is a positive correlation). This positive relationship may be considered as being made up of two components:

•    Past relationship — people with a record of past minor convictions are reportedly more likely to go on to use heroin than, those without such convictions. (This relationship held for some heroin users in some countries in past years, and may or may not apply to Britain today.)
•    Present relationship — people who currently indulge in property crime (street crime, burglary, fencing, shoplifting, credit card fraud, etc.) may celebrate by buying intoxicants and/or food and other goods for themselves and others whenever their activities bear fruit.

As studies of the problem have put it: 'Persons who are very successful in income-generating crimes may spend a sizeable portion of their income on a luxury good — heroin. Then, does the consumption of heroin lead to criminal behaviour, or does criminal behaviour lead to heroin consumption, or both?' (Research Triangle, 1976, p. 22).

In other words, temporary success in crime may lead to a temporary increase in drug use: crime sometimes leads to drug use.

Weighing up the evidence, we can say that the published literature casts doubt on the idea that the best way of understanding the complex relationships between crime and use of drugs is to say that drug use (heroin or other) typically leads to crime against property or persons (Gandossy et al., 1980).

As regards occasional or irregular users — including many of the younger and occasional smokers — money from legal sources, including family pocket-money, is probably sufficient.

Many frequent users may deal in heroin and/or other drugs at least sometimes, and the income from this together with that from legal sources may be sufficient. When it is not sufficient the user may seek either other criminal sources of income and/or a drug clinic supply of legal heroin (which however is very rarely obtained nowadays) or other opiate-type drug. Altematively, he or she may cut down the dose and frequency of drug use. 'There is evidence that the provision of heroin maintenance supplies to clinic attenders reduces the extent of their involvement in crime, though it does not prevent crime altogether (Hartnoll et al., 1980).

The small dealer/user thus has a variety. of alternatives to property crime to support his or her consumption, and the occasional dealer/user generally has no need to 'turn to crime' because an occasional and low level of consumption is not so difficult to underwrite from legal sources of income.

This suggests that if one is concerned to identify one or more 'types' of heroin users who are worth looking at in more detail to see if their drug use positively drives them into crime, it might be most fruitful to look at those poorer users who use relatively heavily, yet do not choose (or are for some reason unable) to support their habit partially through dealing in drugs. There is an obvious need for research into such possibilities in the present British situation.

One useful moral would seem to be that just because heroin misuse, petty property crime, and major crimes of drug trafficking are all bad things, this does not mean that they should be confused and regarded as the 'same thing': separate and specific strategies against each, coordinated within a general programme of enforcement and health measures, may be more effective than a muddled crusade against all three. The next few years carry the opportunity to develop such strategies and evaluate them.

Health and welfare responses

In order to understand some of the debates around treatment, rehabilitation and community responses today, it is helpful to look back a couple of decades. During the 1960s and 1970s heroin injection was the typical mode of administration and smoking the drug was much less common. Most users were over 20 years old, male, and restricted to relatively few geographical areas, especially London and some towns in the south-east. The availability of treatment facilities reflected the pattern of use, with the emphasis being upon the hospital-based drug dependency units (clinics) in London. The clinics were brought into being in 1968, with the intention of bringing heroin users into closer contact with the health and welfare system and breaking their links with private doctors, whose sometimes generous prescriptions fed an illegal market in the drug. By assessing clinic attenders and offering them NHS heroin in injectable form and acceptable doses, the clinics initially managed to attract a large proportion of existing heroin users.

By the mid-1970s, however, it had become clear that the clinics had not been fully successful in containing the problem. Various reasons are given for this: some patients sold part of their clinic supply and bought other drugs or goods with the proceeds (just as SO= patients of private doctors had sold part of their scripts); partly in response to this, clinic psychiatrists had begun to cut down on heroin prescriptions and to offer injectable methadone, oral methadone or juit counselling instead; and world supply of heroin increased during the 1970s. As more and more heroin users approached the clin , the staff (generally consisting of a psychiatrist, nurses and- social worker) increasingly emphasised extended assessment periods to test the would-be patient's 'motivation', and to offer oral methadone for a short period only. Perhaps initial expectations that a clinic supply of heroin would transform sometimes quite delinquent drug users into conformist patients were unrealistic.

The changes that occurred in the health and welfare system in the 1970s were related to the emergence of new and more sophisticated perspectives, stressing social and psychological aspects of dependence as well as physiological dependence. By 1982 the original concept of addiction to a particular drug — heroin — had been displaced in government reports by a broader idea of a diversity of drug-related problems that might be medical, legal, psychological and so on (Advisory Council on the Misuse of Drugs, 1982; see also the concluding chapter in this volume). This may be considered the theoretical reflection of practical changes in and around the clinic system, with medium- and longer-term opioid maintenance being partially displaced by short-term social casework with multi-drug users.

Residential rehabilitation

'Rehabilitation' is the process of learning to live without drugs. In Britain, rehabilitation agencies are generally residential houses that draw upon philosophies developed in north American drug programmes as well as upon British traditions of 'resettlement' and moral reform. The basic idea common to most drug rehabilitation programmes is that a person will not be able to stay off drugs unless he or she changes in some fundamental manner, and that such change is best brought about by becoming a member of a close-knit group. Rehabilitation communities have clear and explicit house rules, and in some houses residents and staff take part in 'encounter groups' and house meetings iri which any departures from the rules are discussed as examples of individuals' immaturity, lack of responsibility and inability to be honest with themselves.

Residents may stay in the house for several months, though it is common for them to 'split' (leave without completing the programme), finding the situation over-demanding and sometimes oppressive (this is sometimes seen as evidence of lack of motivation or honesty by house staff). Some residents develop a pattern of returning and then splitting again several times over a period of years, though some residential houses will be reluctant to take `splittees' back.

Not all residential houses operate programmes of this kind. A few offer supportive accommodation and the availability of counselling and advice, and a number of others rely at least in part on the residents accepting Christianity. The relevance of the residential communities in relation to the new wave of younger heroin smokers and snorters has yet to be determined.

Street agencies

Another type of agency that grew up alongside the drug clinics was the day centre. These were places open to drug users, including clinic attenders, who had little to do during the day other than get into trouble. There were never more than four day centres functioning in Britain, and three of these folded up in the 1960s and 1970s because of the increasing numbers of attenders who took not just heroin but also a range of other drugs such as barbiturates, amphetamines and alcohol (the 'chaotic multi-drug users').

Today the one remaining specialist drugs day centre — Lifeline in Manchester — deals mainly with drug users diverted from the criminal justice system. (That is to say, they are effectively given a choice between jail and rehabilitation.) The other three day centres evolved into advice centres (sometimes called street agencies) that allow drug users on the premises for relatively short periods of time to get information, help with practical problems such as accommodation, social security or referral to rehabilitation houses, and counselling. The main trends here are an increasing interest in the needs of women and the provision of a range of advisory and training services to professionals working in statutory services such as social work and probation (Dom and South 1985).

Non-specialist services

It is increasingly being recognised that users of heroin and other drugs cannot always be handed on to specialist services, if only because those services cannot handle the numbers. And given the realisation of the importance of understanding the person's drug use in the broader context of their involvements with family and friends, work and community, it makes sense for generic case workers such as social workers, probation officers and GPs to be involved. The government has published guidelines of good clinical practice which suggest that all doctors have a role in giving health care (including general health care, counselling, support, and sometimes forms of treatment specific to the drug used) and that there are good reasons for this, quite apart from the fact that there are insufficient specialist drug units to deal with more than a small proportion of problem drug-users. Alan Glanz has recently conducted research into GPs' involvement in treating drug users (Glanz, 1986; see also MacGregor and Ettorre, this volume).

Training is increasingly recognised 'as important, both for those working within specialist drug agencies, and for generic health, social welfare, and education workers. There is also increasing interest in ways of supporting parental and other community self-help groups concerned with drug use on a local level.

Crisis intervention

At the same time, however, there is a minority of drug users who are so 'messed-up' — both in terms of poor physical health and of behaviour — that they cannot be cared for except by a 24-hour specialist residential house, and yet are not willing or not able to behave in ways acceptable to most rehabilitation houses. Examples include people who use drugs heavily whilst they are homeless, or overdose repeatedly, or act in unpredictable or frightening ways.

At present there is only one short-to-medium-term crisis-intervention residential agency in Britain — City Roads in London. This agency began as a short-term house with the emphasis upon medical care and advice work, but then moved more towards the model of a rehabilitation house, laying more emphasis on counselling and demanding evidence of 'motivation' of clients (Jamieson et al., 1984, pp. 170-1). Most of the people approaching crisis intervention and rehabilitation houses are users of a variety of drugs of which heroin may be one.

A new balance of control policies

At the beginning of the section on health and social responses, we described the setting-up of specialist health facilities for heroin users in the 1960s as being (in part at least) an attempt to discourage the development of an illegal market in drugs. That approach can now be seen to have had little success in the face of changing social, economic and drug-market conditions.

What has happened more recently is a widespread attempt to bolster specialist drug services by means of an expansion of non-statutory, community and self-help approaches (residential houses, 'phonelines, parents' groups, etc.). Although the statutory drug services are still there, they no longer rely on heroin maintenance as their main therapeutic tactic. Indeed, non-statutory and community resources outside the clinic system have replaced heroin maintenance inside as the main adjuct to primary health services in the British system of care and control. We cannot say how permanent this shift in the balance of care and control will turn out to be, since this will depend partly on future patterns of funding and partly on shifts in broader social and economic policies.

So, whilst in the enforcement system there have been fresh attempts to deter drug traffickers and suppliers by means of heavier penalties and the threat of forfeiture of their assets (see preceding section on crime), within health and welfare systems there has been a shift in the balance between 'medicinal' (heroin and methadone maintenance) and 'community' (social work plus parents) strategies. One of the broad aims of the government mass media anti-heroin campaigns in 1985/6 and 1986/7 was to encourage parents to take more responsibility for responding to heroin problems (Dorn, 1986, p. 8). Overall, taking the fields of enforcement and treatment together, the result is a parti4 'de-medicalisation' of the problem, the stimulation of a (still patchy) range of welfare and advice services and, possibly, the strengthening of links between policing and community involvement. How this still-developing continuum of care and control holds up in the face of new patterns of drug use such as more widespread heroin smoking remains to be seen.

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